By Ann Crawford-Roberts along with the Icahn School of Medicine at Mt Sinai Student Chapter of Doctors for America
A dozen medical students who form the Icahn School of Medicine at Mount Sinai chapter of Doctors for America have been workingthis year to educate ourselves and our communities about the Affordable Care Act (ACA) and to increase enrollment in its programs.
Here we present seven lessons about ACA implementation that we’ve learned from our work in East Harlem. We hope these insights help fellow advocates across the state and nation, recognizing the specifics and nuances of the local context throughout.
Where are the uninsured? The difficulty of reaching those without insurance
Reaching people without insurance has presented a significant challenge, for our group, as well as for the community organizations and health clinics that we’ve been working with. We’ve found that our partner organizations don’t necessarily have many uninsured among those who already use their services. For example, an East Harlem clinic that offers healthcare to the uninsured doesn’t always have large numbers of uninsured patients coming through their doors, since many of their patients are already enrolled in Medicaid. To reach people without insurance, we needed to join community events and partner with organizations that provide social services, but not necessarily health care. A future direction for our group will be to work with churches, schools, and small businesses to reach broader audiences. In other words, “in-reach” is not enough; significant outreach is essential.
In East Harlem, among the uninsured, immigrants are particularly difficult to reach. Because of unclear public information and fear that residency status will be shared with enforcement, immigrants are often hesitant to seek out services that they or their children may be eligible for. This is a group of the uninsured we need to better reach.
What do we know? The value of information
The second lesson is no secret: there is great misinformation and lack of knowledge about the Affordable Care Act. Recent Kaiser Health surveys, shows that half of people without insurance don’t know about the major provisions of the ACA, and four in ten respondents are unsure if the law has been repealed or is still being implemented. And it’s not just the people who could benefit from the law who don’t know enough about it. Community organizations and their employees, social workers, healthcare providers and medical students don’t have a good working knowledge of the law.
Countless people have told us that they’ve heard conflicting information about the law itself and don’t know whether it applies to them. With this highly politicized law and false rumors surrounding it, media coverage and public campaigns must be clearer and more effective at informing people about their options and encouraging them to enroll. We’ve witnessed the value of focused education on the ACA: a high proportion of the people who attended our information sessions who were uninsured now have insurance after learning about the law and connecting with in-person assistance. The ACA is a complex law, and therefore the value of concerted public educational efforts cannot be overstated.
In addition, we’ve observed the need for educational campaigns and public messages to better inform immigrants about their eligibility. While there has been a large focus, nationally and locally, on reaching young people, few resources have been dedicated to informing immigrants how they could benefit from the law and reassuring them that their personal information will not be shared with enforcement. Again, this is a group, especially important to us in East Harlem, that needs to be better reached.
What are people not doing? The division of roles & diversion of resources
The time, energy, and resources needed to implement the ACA’s substantial programs pull community organization staff from their usual work of providing services. This is especially true when the in-person assister role (navigator or certified application counselor, CAC) is split between many people. For example, some community centers and health clinics have funding for one or two full time equivalent (FTE) navigators, but may divide the role between four people, with each person spending 1/4th of their time on ACA education and enrollment, often in addition to their other responsibilities. Organizations have reported that even with additional funding, their resources, including staff, funds, and time, are being stretched to accommodate ACA programs.
What are we waiting for? Logistical snags
Many of us have already heard of the organizational delays and difficulties we list below. Though some may be understandable, the result of the implementation of a large law with its many programs, these logistical barriers could have been foreseen and better planned for:
The delay of the fully functioning state exchange website
The delay in training materials
A requirement that documents be faxed to the state health department
A lack of a comprehensive and accurate list of navigators/CACs
The delay of Spanish state exchange website in New York, an especially important tool in our community
Who is supporting us? The division between state & local government
We’ve learned that in New York State, the implementation of this federal law at the local level is being carried out by the state. It is not within the mandate of the city or municipal local governments to be a part of this effort. Given the gaps in implementation we have seen, we wonder if the ACA implementation might be more successful if the city were involved.
What are other people doing? The need for communication and collaboration
An additional challenge we have encountered is that organizations and clinics haven't had many opportunities to share their resources and valuable experiences with each other. Because this was the first year of enrollment in new plans and programs, there’s been quite a learning curve. We’re all learning, observing, and making adjustments. It is critical that clinics, community organizations, and navigators/CACs have the space and time to collectively identify challenges and share best practices. Such communication and collaboration could prove invaluable. One of our primary goals through our work in East Harlem is to facilitate such communication and collaboration, but this role goes unfilled in many communities.
What has worked? The successes
Despite the challenges identified in this list, there have been successes. Nationwide, 8 million people have signed up for private insurance in Health Insurance Marketplaces and 6,700,000 more people have been enrolled in Medicaid and CHP. In New York State, 650,000 people have enrolled in a private plan and 370,000 additional people have signed up for Medicaid and CHP. Each of those millions of people has improved healthcare access and protection from financial bankruptcy due to healthcare costs, and, with this new security, peace of mind.
We’ve seen that a successful approach to getting people covered involves integrating ACA education and enrollment into other services and programs, such as when a health center screens all patients for insurance status, with a navigator reaching out to those who are flagged as uninsured. Or when a community service agency includes insurance screening in their tax clinics and links people to navigators. Or when we as students have the chance to go into adult education classes and teach about the ACA.
We’ve also found that success depends on connections between the people and resources that already exist. Community leaders, local government officials, and religious congregations need to be linked with navigators/CACs and information about the ACA.
Moving forward into the next enrollment cycle, our DFA chapter hopes to do just that: we plan to continue teaching about the law, supporting ACA services integrated into existing resources, and facilitating communication and coordination among the various actors involved in the ACA in East Harlem. We look forward to partnering with others involved in this important work.